Authorization for Access to Patient Information Through a Health Information Exchange Organization PROVIDER -

Provider

Patient Name*

Date of Birth*

Patient Identification Number

Address*

Street Address Address Line 2 City State ZIP Code

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow the above-named Provider Organization or Health Plan; or reference to a list of specific Provider Organizations and/or Plans attached to this form to obtain access to my medical records through the health information exchange organization called Rochester RHIO. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Rochester RHIO is a not-for-profit organization that shares information about people’s health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit Rochester RHIO’s website at www.RochesterRHIO.org.

My information may be accessed in the event of an emergency, unless I complete this form and check box #2, which states that I deny consent even in a medical emergency.

The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

» Details about the information accessed through Rocheter RHIO and the consent process can be found here.

Consent Choice

ONE box is checked to the left of my choice. I can fill out this form now or in the future. I can also change my decision at any time by completing a new form.

I GIVE CONSENT for above-named Provider Organization, or Health Plan or reference to a list of specific Provider Organizations and/or Plans to access ALL of my electronic health information through Rochester RHIO to provide health care services (including emergency care).
I DENY CONSENT for above-named Provider Organization, or Health Plan or reference to a list of specific Provider Organizations and/or Plans to access my electronic health information through Rochester RHIO for any purpose, even in a medical emergency (except for minor patients).

Print Full Legal Name*

By entering your full legal name, you are signing this agreement electronically. You agree you are the patient or the patient’s legal representative, authorized to sign on the patient’s behalf. Your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting a consent choice above you consent to be legally bound by this agreement’s terms and conditions.

Relationship to Patient*

If you are signing for the patient, please state relationship of legal representative to patient. If you are the patient, enter “Self”

Hidden

Date Electronically Signed